Provider Demographics
NPI:1164641007
Name:MCCOOL, MICHAEL JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:MCCOOL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 N BRADY ST
Mailing Address - Street 2:5S
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-3969
Mailing Address - Country:US
Mailing Address - Phone:563-386-9770
Mailing Address - Fax:563-386-9015
Practice Address - Street 1:4711 N BRADY ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-3969
Practice Address - Country:US
Practice Address - Phone:563-386-9770
Practice Address - Fax:563-386-9015
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA066851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0007583Medicaid